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Car Accident
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Work Related Injury
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Headache
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Neck Pain
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Mid Back Problems
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Low Back Problems
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TMJ/Jaw Problems
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Dizziness
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Shoulder Pain
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Elbow Problems
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Carpal Tunnel Syndrome
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Bulging Disc
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Wrist Pain
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Facial Pain
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Hip Problems
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Knee Problems
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Ankle/Foot Problems
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Plantar Fasciitis
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Arthritis
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Sports Injury
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Intake Questionnaires
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Neck Questionnaire (click on)
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Neck Index
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Pain Intensity
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Concentration
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Personal Care
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Work
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Lifting
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Driving
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Reading
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Sleeping
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Headaches
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Recreation
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Index Score = [Sum of all statements selected / (# of sections with a statement selected x 5)] x 100
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Neck Index Score
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Back Questionnaire (click on)
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Back Index
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Pain Intensity
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Standing
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Personal Care
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Sleeping
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Lifting
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Social Life
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Walking
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Traveling
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Sitting
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Changing degree of pain
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Index Score = [Sum of all statements selected / (# of sections with a statement selected x 5)] x 100
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Back Index Score
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SHOULDER PAIN AND DISABILITY INDEX (SPADI)
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SHOULDER PAIN AND DISABILITY INDEX (SPADI)
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How severe is your pain?
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1. At its worst?
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2. When lying on the involved side?
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3. Reaching for something on a high shelf?
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4. Touching the back of your neck?
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5. Pushing with the involved arm?
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How much difficulty do you have?
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1. Washing your hair?
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2. Washing your back?
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3. Putting on an undershirt or pullover sweater?
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4. Putting on a shirt that buttons down the front?
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5. Putting on your pants?
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6. Placing an object on a high shelf?
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7. Carrying a heavy object of 10 pounds?
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8. Removing something from your back pocket?
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OTHER COMMENTS
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The Migraine Disability Assessment Test
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The Migraine Disability Assessment Test
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Please read below and answer the following
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1. On how many days in the last 3 months did you miss work or school because of your headaches?
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2. How many days in the last 3 months was your productivity at work or school reduced by half or more because of your headaches?
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3. On how many days in the last 3 months did you not do household work (such as housework, home repairs and maintenance, shoppin
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4. How many days in the last 3 months was your productivity in household work reduced by half of more because of your headaches?
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5. On how many days in the Iast 3 months did you miss family, social or leisure activities because of your headaches?
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Total (Questions 1-5)
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What your Physician will need to know about your headache
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A. On how many days in the last 3 months did you have a headache? (ll a headache lasted more than 1 day, count each day)
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B. On a scale 0f 0 your headaches? - 10, on average how painful were these headaches? (where 0=no pain at all, and 10= pain as
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Scoring: After you have filled out this questionnaire,add the total number of days from questions 1-5 (ignore A and B)
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Please read below
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KNEE EVALUATION FORM
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SYMPTOMS
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Please read below and answer the foilowing
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1. What is the highest level of activity that you can perform without significant knee pain?
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2. During the past 4 weeks, or since your injury, how often have you had pain?
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3. If you have pain, how severe is it?
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4. During the past 4 weeks, or since your injury, how stiff or swollen was your knee?
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5. What is the highest level of activity you can perform without significant swelling in your knee?
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6. During the past 4 weeks, or since your injury, did your knee lock or catch?
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7. What is the highest level of activity you can perform without significant giving way in your knee?
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SPORTS ACTIVITIES
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8. What is the highest level of activity you can participate in on a regular basis?
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9. How does your knee affect your ability to
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a. Go up stairs
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b. Go down stairs
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c. Kneel on the front of your knee
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d. Squat
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e. Sit with your knee bent
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f. Rise from a chair
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g. Run straight ahead
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h. Jump and land on your involved leg
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i. Stop and start quickly
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FUNCTION
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10. How would you rate the function of your knee on a scale of 0 to 10 with 10 being normal, excellent function and 0 being the
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FUNCTION PRIOR TO YOUR KNEE INJURY
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CURRENT FUNCTION OF YOUR KNEE
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Scoring Instructions for the 2000 IKDC Subjective Knee Evaluation Form
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QUADRUPLE VISUAL ANALOGUE SCALE
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Example - Please read below
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1. What is your pain RIGHT NOW?
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2. What is your TYPICAL or AVERAGE pain?
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3. What is your pain level AT ITS BEST (How close to “0” does your pain get at its best)?
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What is your pain at WORST? (How close to "10" does your pain get at its worst)?
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What percentage of your awake hours is your pain at its best?
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What percentage of your wake hours is your pain at its worst?
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SCORE
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